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Bicycle Incident Report
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A
General Info |
Todays Date: |
| Name: | |
| Address: | |
| Phone: | |
| Email: | |
| Are you a: Commuter____, Recreational Rider_____, Racer_____, Other_____ (please specify) | |
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| B Incident Info |
Date of Incident: |
| Street Name: | |
| Time of Day: __am __pm | |
| Weather Conditions: | |
| Were you riding alone? Yes___ No___ | |
| Number of lanes on street: | |
| Bike Lane? Yes___ No___ | |
| Sidewalk? Yes___ No___ | |
| Lighting Condition: dusk___, dawn___, daylight___, darkness w/street lighting___, darkness without street lighting___ | |
| Traffic Volume: none___, light___, moderate___, heavy___ | |
| Road Configuration: one way___, two way___, divided highway___ | |
| Road Feature: 4-way intersection___, T-intersection___, side street___, private drive___, parking lot___, railroad crossing___, hill crest___, blind curve___, other (please describe):________________________ | |
| You were: riding with traffic___, stopped at intersection___, making left turn___, making right turn___, riding against traffic___, other (please specify)____________________________________________________ | |
| You were located: shoulder___, sidewalk___, bike lane___, right third of lane___, center of lane___, left third of lane___ | |
| Equipment: headlight___, tail light___, reflector___, vest/banner___, other_________________________ | |
| Did you file a police report? Yes___, No___ Type of Report: Accident___, Offense___, Report #__________ | |
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C
Incident Involving another Vehicle |
Was this Incident involving a vehicle? Yes___, No___ If yes proceed through section C. If no, go to section D. |
| Please describe the incident: | |
| Please describe any information about the vehicle: | |
| Please describe any information about the driver (sex, approximate age, etc.): | |
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| D Non-Vehicular Incident |
The non-vehicular incident involved (please check and describe): |
| Signage___ | |
| Broken Pavement___ | |
| Animal(s)___ | |
| Landscaping___ | |
| Railroad Tracks___ | |
| Road Hazard___ (please describe)_____________________________ | |
| Other___________________________________________________ | |
| Please describe what occurred: | |
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| E Additional Info |
Please include any additional comments such as what can be done to prevent this incident from occurring again: |
| Would you be interested in receiving future updates on bike and pedestrian events and meetings via email? Yes___ No___ | |
| Please remit to: Claudia Nix at Liberty Bicycles, Inc. 1378 Hendersonville Hwy. Asheville, NC 28803. | |